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1 TITLE/DESCRIPTION: DEPARTMENT: PERSONNEL: BLOOD PRODUCT ADMINISTRATION CLINICAL LABORATORY ALL HOSPITAL EMPLOYEES EFFECTIVE DATE: 10/95 REVISED: 7/03, 03/05, 04/08, 3/10, 11/11, 09/13, 3/14,1/15, 4/16 RESPONSIBILITY FOR FINAL IDENTIFICATION CHECKS: In the Patient s Room or Outpatient IV Services, Transfusion Record Manager (TRM) must be used at the bedside to verify the patient and blood product. The person actually starting the transfusion and another nurse must together recheck the correspondence of blood product unit numbers and blood type labels on the unit, and the Blood Band Identification (BBID) number with the unit tag. Then ABSOLUTELY VERIFY that the patient identification (Name, DOB and MRN) on the unit tag corresponds to the armband and the blue blood bank armband identity of the patient. This verification must be documented by both persons, by electronically signing the Blood Administration Record in the HIS. This MUST occur at the bedside. In the Operating Suite, the person actually starting the transfusion and another nurse/md must together recheck the correspondence of the blood product unit numbers and blood type labels on the unit, and the BBID number with the unit tag. Then ABSOLUTELY VERIFY that the patient identification on the unit tag corresponds to the armband and the blue blood bank armband identity of the patient. This verification must be documented in the electronic OR Blood Administration Record, by typing in the identity of the administering and verifying personnel in the appropriate spaces. If any discrepancy arises as a result of these checks, the blood should be returned to the Blood Bank immediately. RETURN OF BLOOD PRODUCTS TO BLOOD BANK: All blood product units issued for transfusion should be started immediately after being issued. If it becomes apparent that the unit cannot be started immediately, it should be returned to the Blood Bank without delay (not kept at room temperature or placed in an unmonitored refrigerator). If the start of the transfusion is delayed, the following guidelines must be followed: a. The transfusion must be completed within 4 hours from issue from the controlled storage, not 4 hours from the start of administration

2 b. If the product temperature rises above 10 degrees, the product must remain on the unit and transfusion completed within 4 hours from issue from the controlled storage. c. If the product is not needed by the patient, but failed to be returned to the Blood Bank immediately and product is now out of temperature; the product must be returned and discarded by Blood Bank personnel to prevent re-issue. Due to rigid regulations and the need to curtail unnecessary loss of blood products, it is requested that the responsible nurse verify that transfusion can be started prior to pick-up of blood product. On difficult to stick patients, it is recommended that an I.V. be started with normal saline at a T.K.O. rate (EXCEPT WHERE INFUSION OF SALINE IS CONTRAINDICATED) before picking up the blood product. Blood products issued to the CVOR Pump Room are stored in a monitored refrigerator (except platelets) during the case. All un-used blood products should be returned to the Blood Bank within 20 minutes of the case ending, so the products will be available for transfusion in cardiac recovery if needed. ADMINISTRATION OF BLOOD PRODUCTS: The requirements for administration of blood products must be closely followed and the required documentation fully completed. In the administration of blood products, the final verification that the information on the patient's arm band, blood container label, and unit tag all correspond, must be the immediate responsibility of a registered nurse or physician. Prior to starting the blood product, the patient's blood pressure, pulse, respiration and temperature must be taken and recorded on the electronic Transfusion Record. BLOOD PRODUCTS SHOULD BE STARTED WITHIN 30 MINUTES AFTER ISSUE FROM BLOOD BANK. The unit should be entered only after it is determined that there is no reason not to start the transfusion. Pre-transfusion vital signs should be taken before spiking the unit. The blood product must be started and administered slowly for fifteen minutes, unless specified otherwise by the physician's orders. A nurse should stay with the patient for the first minutes to ensure there are no symptoms of a reaction. After fifteen minutes, the vital signs and temperature must be taken again and recorded on the transfusion record. If no adverse effects are apparent, the rate of flow should be increased such that the transfusion will be completed within two to three hours. The vital signs and temperature must again be taken at the conclusion of the transfusion. The time of completion of the transfusion must be recorded on the Transfusion Record, as well as the amount transfused. All electronic Transfusion Records should be complete within 72 hours.

3 If transfusion record results are not entered electronically, due to HIS downtime or other issues, the white paper Chart Copy must then be inserted in the patient's chart as part of their permanent medical record. The third hard copy of the unit tag MUST remain attached to the blood product unit, until transfusion is complete and the empty bag is discarded. All routine transfusions should be documented electronically in the Blood Administration Record. Emergent transfusions should be documented electronically in the Emergent Blood Administration Record. Emergency transfusions are primarily for use in the Emergency Department, Critical Care Units, and codes. Vital signs are not required on this document. There is a statement directing to the Vital Sign Flow sheet for Vital Signs. Any transfusion that is completed in 15 minutes or less should use this document. All blood product transfusions performed in the Operating Suite, should use the OR Blood Transfusion Record. This record is specifically tailored to the needs of the operating room staff. All patients receiving blood product transfusions as an outpatient in the Outpatient IV Services area will receive a Post Transfusion Letter prior to discharge. The Post- Transfusion Letter details symptoms noted within 24 hours post-transfusion, that may be indicative of a potential transfusion reaction. PRECAUTIONS: The administration of any blood product must be discontinued at FOUR HOURS from issue of product from controlled storage. All blood products are transfused using the Y type blood set. Blood may be warmed as it passes through the set with a special blood warmer having a visible thermometer and an audible alarm. Temperature should not be allowed to exceed 42 0 C; blood should be discarded if temperature exceeds 42 0 C. Any devices (blood warmer) used during the transfusion should be noted on the transfusion record so the Blood Bank Director may be fully aware of device usage in the event a transfusion reaction investigation becomes necessary. If multiple units are given, a new set should be used with each unit. Addition of drugs or medication, including those intended for intravenous use, must not be added to blood products. Only 0.9% Sodium Chloride injection, USP, may be added to blood products. If a physician specifically requests the addition of a medication, the Blood Bank Director must be contacted PRIOR to the addition. Medications are not to be omitted due to the administration of blood products unless specifically ordered to do so by a physician. If necessary, the nurse may start a heparin

4 lock to give medication through. Under no circumstance should medication or other substances be given through an IV line in which blood is being infused. Persons overseeing patient transfusions must be knowledgeable of the signs and symptoms of the various types of transfusion reaction. A complication of a blood transfusion is a hemolytic transfusion reaction. There are several other types, as shown in Table 1 (attached). During transfusion, the condition of the patient should be checked as frequently as circumstances allow, in that the severity of any given type of reaction is almost always worsened by the continued transfusion of the offending blood product. The slow rate of blood flow during the first part of a transfusion is to permit the possible detection of reaction symptoms without giving the patient a large volume of the unit. The major symptoms and signs of a reaction are chills, fever, headache, backache, hematuria, localized edema, bronchial spasm, skin rash or wheals, and itching. Some patients may experience a mild chilly sensation simply as a result of receiving the blood at refrigerated temperature, this may require evaluation by the head nurse in the individual case. Some judgment may also be required with regard to the appearance of fever during the transfusion in a patient already experiencing documented recurrent febrile episodes. TRANSFUSION REACTION PROCEDURE: If any signs or symptoms of a reaction appear during a transfusion, the following sequence of procedures will apply: IN ALL CASES EXCEPT "HIVES" ONLY; cut off the flow of blood through the recipient set and remove set from venous catheter -- DO NOT REMOVE CATHETER. Start a unit of normal saline at a T.K.O. rate to prevent clotting in the needle. NOTE: If no other symptoms are present except "hives" reduce the rate of infusion and stop only if directed to do so by the physician. RECHECK the patient's identification with the blood product. Take the patient's vital signs and temperature. Notify the Blood Bank. Notify the attending physician. On the transfusion portion of the Blood Administration Document (Transfusion Record), document vital signs, time transfusion discontinued and approximate amount of blood product infused.

5 Order Transfusion Reaction Work-Up in HIS and enter the requested information. Send blood product bag (with set intact but tied off or clamped (including saline bag) in a plastic bag with Transfusion Record form attached to outside of plastic bag (do not place inside with blood product bag). Send the FIRST AVAILABLE urine specimen to the Lab. RECORD URINE OUTPUT FOR THE NEXT TWENTY-FOUR HOUR PERIOD SUBSEQUENT TO THE APPARENT REACTION. Draw a blood bank sample for repeat testing and deliver to the blood bank. The blood bank staff will generate a transfusion reaction investigation report. TRANSFUSION REACTIONS: OTHER TRANSFUSION COMPLICATIONS ANY transfusion related incident should be reported IMMEDIATELY to the Blood Bank/Laboratory Medical Director or the Laboratory Director, regardless of the outcome to the patient (transfusion of blood products to the wrong recipient, transfusion of the wrong unit to a patient, discovery of a discrepancy between a patient's historical blood type and type currently recorded on paperwork, or appearance of delayed transfusion reaction symptoms). Laboratory will notify nursing personnel of discrepancies discovered in paperwork PRIOR to transfusion. The development of unexplained acute liver dysfunction or clinical symptoms suggestive of hepatitis (within two weeks to six months) after transfusion of blood or blood components should be reported to the Medical Director or Laboratory Director. The FDA requires investigation of such cases as possible post transfusion hepatitis, and notification of the blood supplier.

6 Table 1: Signs and Symptoms of a Transfusion Reaction

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